Depression Management in the Workplace

OBJECTIVE
To review a case of a depression management program at PPG Industries with the potential to improve outcomes on functioning and productivity in the workplace.


SUMMARY
The need for major improvements in depression management has been well established. While most in the corporate world are aware of these deficiencies, the perception is that this fragmented system is difficult to change. PPG Industries, a medium-sized, Fortune 500 company manufacturing paints, stains, and sealants, has launched a successful and comprehensive program in the workplace that has improved outcomes for depressed employees. The PPG approach is practical, addressing each step in the process one at a time. This process began by establishing a close working relationship between all entities responsible for employee health, many of which are currently carved out. This enabled the company to have a comprehensive view of their depressed population and to examine their functional outcomes as well. In an effort to help identify depressed employees, the company educated their physicians and care managers and launched a confidential Web site to reduce mental health stigma and aid in employee screening and education. A multidisciplinary team was then assembled to facilitate the treatment of these patients. All of these steps were measurable, and the preliminary results of this process are summarized.


CONCLUSION
A disease management program that incorporates a multifaceted, collaborative approach to treat depression is feasible and may improve care and decrease cost to employers.

D e p ression is widely acknowledged in the corporate world as a topic worthy of much attention. 1 , 2 Most of us are a w a re that improvements are desperately needed in the way we approach depressed employees, but few of us sincere l y believe we can do anything about it. I strongly believe that it is possible to change this situation, and I would like to share our experience at PPG Industries with you. It may not be an entire l y scientific approach, but it is a practical one and should be thought of as more of a cultural anthropology endeavor than a bioscientific e x p e r i m e n t .

■ ■ Embracing Change
The first challenge in improving depression management in the workplace is to try to change the relationships between all stakeholders-patients, providers, pharmacists, psychiatrists, medical practices, plan purchasers, and data managers. Many aspects of c a re are carved out these days, but we need to all get together and center on the patient' s well-being, focusing on an improved continuum of care. Historically, we all have looked at the situation f rom our own perspectives and, from an employer' s vantage point, cutting costs or services has seemed the most logical appro a c h . H o w e v e r, the quality of care often suffers when we approach the situation in this manner. And bad care and bad perf o rmance is really the most expensive and wasteful solution.
So the first step is to bring all the diff e rent players to the table to reconstitute the flow of information. We need to have the right i n f o rmation at the right time in the right place when it is needed. Sharing and reintegrating the data among all the players is pivotal if we are ultimately to effect change in this pro c e s s .

■ ■ Surveying the Landscape
The next step in improving the management of depression is to use the data we've shared to assess the landscape pert a i n i n g specifically to our depressed employees. In the case of PPG, we used published data available in the medical literature but also relied upon Medstat (a health information company) to assemble data specific to our employee pool. Medstat integrated all the relevant and available costs (e.g., medical, prescription dru g , absenteeism, and disability expenditures) and ranked the physical and mental conditions based on costs to the employer.
The impact of depression and other affective disorders on our expenses at PPG was predictably large, and we wanted to figure out the risk factors predisposing employees to these conditions and ascertain whether or not these were reversible. Historically, s t ress has been closely associated with depression, but we also wanted to look at the relative influence of other risk factors and try to identify causes that we could modify. 3 , 4 Our re s u l t s demonstrate that stress is, in fact, most closely associated with the p revalence and severity of depression but that few people were re a d y, willing, and able to change. In general, if employees demonstrate a willingness to change certain risk factors, then the D e p ression Management in the Wo r k p l a c e : A Case Study

A B S T R AC T
OBJECTIVE: To review a case of a depression management program at PPG Industries with the potential to improve outcomes on functioning and productivity in the workplace.
SUMMARY: The need for major improvements in depression management has been well established. While most in the corporate world are aware of these deficiencies, the perception is that this fragmented system is difficult to change. PPG Industries, a medium-sized, Fortune 500 company manufacturing paints, stains, and sealants, has launched a successful and comprehensive program in the workplace that has improved outcomes for depressed employees.
The PPG approach is practical, addressing each step in the process one at a time. This process began by establishing a close working relationship between all entities responsible for employee health, many of which are currently carved out. This enabled the company to have a comprehensive view of their depressed population and to examine their functional outcomes as well. In an effort to help identify depressed employees, the company educated their physicians and care managers and launched a confidential Web site to reduce mental health stigma and aid in employee screening and education. A multidisciplinary team was then assembled to facilitate the treatment of these patients. All of these steps were measurable, and the preliminary results of this process are summarized.
workplace is mature for the deployment of a program. If there is a high prevalence but little readiness to change (as was demonstrated with stress and depression at PPG), then we need to focus on creating awareness and providing education.
We also looked at the mental health landscape through dru g utilization patterns. Working closely with Caremark, our p h a rmacy benefits management company, we analyzed antid e p ressant utilization (as well as utilization of other medication classes) and quickly realized that our depressed population was s u ffering from many other medical comorbidities as well. They w e re very heavy utilizers in general. We also analyzed the demographics of who was receiving prescriptions, as well as who was writing them (i.e., prescribers' medical specialty). We learn e d , for instance, that men and women were equally likely to re c e i v e an antidepressant prescription and that the likelihood of doing so i n c reased with age, peaking in the geriatric population ( Figure 1). Analysis of the provider data revealed that most antidepressants w e re being prescribed by providers in the fields of family medicine and internal medicine, so we were now aware that the p r i m a ry care setting was the front line ( Figure 2).
Another source of vital information came from a regional study known as the Southwestern Pennsylvania Depression Report (SPDR). The SPDR demonstrated that the highest hospitalization rate for depression was in the group aged 30 to 39 years, a demographic that is at the peak of their productive years. Using the classic depression quality indicators from the Health Plan Employer Data and Information Set, the SPDR revealed that only 10% to 38% of patients received follow-up for their antidepre s s a n t t reatment after discharge, and 13% of these patients were readmitted within 30 days of discharge. This study pro v i d e d s t rong evidence of the poor quality of care that depressed patients received. Follow-up was inadequate and coordinated care was l a c k i n g .
A comprehensive analysis of our particular landscape, theref o re, was fairly consistent with what has been re p o rted nationally. 5 , 6 The health care delivery system for mental health, including d e p ression, is very fragmented, with little collaboration between p r i m a ry care, specialty care, employee assistance, and pharm a c y. M a n y, if not all, components have been isolated or carved out, and t h e re are no identifiable incentives for integrating diagnosis, medication management, therapy, and follow-up. What we have ultimately created is a shattered mirror where it is very difficult to accurately recompose the original image.

■ ■ Changing the Workplace Environment
Although the stigma surrounding mental illness may have diminished somewhat in recent years, it still exists, and we need to deal with it eff e c t i v e l y. To reduce stigma in our workplace, we emphasized the benefits of early recognition through We b -b a s e d s c reening and the availability of functional rehabilitation. As studi e s have shown, however, it is not enough to simply screen for d e p ression-a program of coordinated care must also be in p l a c e . 7 , 8 Integration must occur, there f o re, between primary care and behavioral health specialists, and effective tools must be placed in the hands of providers to enhance treatment and patient education. Most of all, we strived to provide depressed patients with an experience of continuous pro g ressive care to p revent them from falling through all the traditional cracks in the s y s t e m .
At the point of service, we elected to train our nurses to fill the role of care managers. The goal was to enable them to serve as facilitators to help patients or employees navigate through the system, accessing support services such as the PPG Employee Assistance Program (EAP). We didn't want the nurses to become p h a rmacists, providing expert medication management. We didn't want them to become psychiatrists, providing formal diagnosis a n d c o m p rehensive treatment plans. And we didn't want them to be psychologists either, delivering behavioral therapy. We trained our nurses to be facilitators and educators, helping to elevate depre s s i o n to the level of other conditions such as high cholesterol and high blood pre s s u re in our wellness activities. This emphasis upon depression, wellness, and the role of nurses in our system was also conveyed effectively to our employees. We let them know about the accessible Web-based screening tools for depression and that standardized guidelines for treatment were readily available. We also gave them a good idea of what to expect when they went to a physician seeking help for their depre s s i o n .
The integration of health care specialists re q u i res that care f u l thought also be devoted to identifying where the expert support should come from. From my perspective, expert support can be p rovided by psychiatrists, psychologists, or pharmacists, depending on your specific institutional re s o u rces. I believe that p h a rmacists should seriously consider developing a role in managing depression that is analogous to certified diabetes e d u c a t o r s . 9 P h a rmacists could be formally trained to arrive at worksites or come to employers with the expressed purpose of educating them about depression and its appropriate treatment. I would encourage pharmacists to consider this role and the additional value it would bring to patients and to the pro f e s s i o n .

■ ■ The PPG Experience
One year ago, we embarked on this ambitious project, bringing all the stakeholders together for the first time. This first step was critical but we had to get all of them together, including the b e h a v i o r a l health carve-out, if we were to make it work (Figure 3).
The method we chose for training the trainers (i.e., the nurses) was to put together a series of seminars, which included a day-long conference as well as 9 hours of Web-site instru c t i o n . The Web casts, in part i c u l a r, re p resented a more cost-eff e c t i v e a p p roach to us, and we used the opportunity to emphasize such topics as appropriate use of the screening tool (PHQ9), mechanics of effective collaborative care eff o rts, and methods to impro v e access to employer assistance programs. None of this was re v o l ut i o n a ry -it was just a very practical approach to laying down the foundation for our interv e n t i o n .
S i m u l t a n e o u s l y, we also had to reach out to the primary care physicians to improve their ability to identify and successfully manage depressed patients. The logistics of reaching out to a larg e pool of physicians is often daunting, so we wanted to make our a p p roach more tangible by identifying exactly how many practices and providers we were talking about. We wanted to make everyone more comfortable by demonstrating that it was a finite number of physician practices that we were reaching out to: 62, in our case, would cover 50% of our employees. Our health plan (Highmark) then started working with the larger primary c a re practices first, sending out liaison personnel to train the physicians in the use of screening tools and circulating the AMA toolkit for depression. Highmark also created pre s c r i p t i o n pads to facilitate the necessary re f e rrals (e.g., to educational and support s e rv i c e s ) .
Another feature of our primary care intervention was to open up direct access for patients to behavioral health specialists. A 24-hour telephone support service was also created for patients with more urgent needs.
Once patients were initiated on medication, we wanted to make sure that they gave the antidepressant a full therapeutic trial and, if successful, that they continued to take it for a minimum of 6 months. The only good medicine is the medicine people actually take, and studies have shown that most patients stop their antid e p ressant before 6 months. 6 C o n s e q u e n t l y, we emphasized to p roviders and care managers that they needed to convince patients that they are active players in treating their own chronic conditions. In surg e ry, the surgeon knows what to do, and a general assembly is not usually re q u i red to decide which surg e ry is appropriate. In chronic care, successful treatment re q u i res

Measuring Outcomes
As mentioned pre v i o u s l y, we have established a variety of objectives for the various stages in the disease management p rocess. Aw a reness, early recognition, treatment, follow-up, and monitoring adherence have all been cited. For the sake of evaluating our relative success, we had to identify or create methods to measure our impact upon every step in this pro c e s s .  (Table 1). There was also a significant increase in the number of employees using the Web-based screening tool (from 5 to 42) and in the number contacting EAP for assistance (from 42 to 157). Several data points, there f o re, suggested to us that the a w a reness intervention was translating into increased access and i n c reased utilization of frontline serv i c e s . This increase in awareness and assessment also appears to be equating to an increase in the number of verified depression cases. During the past year, we saw a 30% increase in the number of cases opened by EAP (from 63 to 82). As other experts have mentioned, lost productivity re p resents the greatest cost to employers, and we are beginning to witness significant impro v ements in this re g a rd as well. 1 0 F rom a survey administered to the EAP cases, we learned that employees experienced a substantial Return to Function: Impact on Health and Productivity i n c rease in functionality at home and in the workplace (Table 2). S e l f -re p o rts of absenteeism suggest that lost work days have also diminished among our depressed employees. Although our findings in the productivity spectrum are favorable, we hope that m o re sophisticated tools can be developed in the future that will give us a more comprehensive look at the impact of depression on functionality in the workplace. We hope that a measure of physician p e rf o rmance can be integrated some day as well.

■ ■ Conclusion
I hope that my description of the PPG experience has convinced you from a practical perspective that it is possible to effect change in the way depression is managed by employers. The first and most crucial step is to get all the stakeholders together to share their information. Once this data is analyzed, we need to pursue a collaborative approach to improving detection, treatment, and follow-up. The employee or patient must be motivated to become an active member of this treatment team. If such collaboration can be accomplished, improved care and reduced costs are very much achievable objectives.

DISCLOSURES
Funding for this study was provided by the 2003 Innovation Award from the Institute for Occupational and Environmental Health, obtained by the author. The author received an honorarium for participation in the symposium upon which this article is based. He discloses no potential bias or conflict of interest relating to this article.